Increased vigilance needed to prevent kernicterus in newborns
- Copyright © 2001 by the American Academy of Pediatrics
Pediatricians are being asked to renew their efforts to keep kernicterus in check. To that end, AAP members are advised to follow the AAP practice parameter titled, Management of Hyperbilirubinemia in the Healthy Term Newborn (Pediatrics. 1994;94:558-565OpenUrl).
“Kernicterus is rare but it still occurs and pediatricians need to be cognizant of this,” said Jeffrey Maisels, M.D., FAAP, chair of the AAP Subcommittee on Neonatal Hyperbilirubinemia. He added that the guidelines are under revision, but are still current and, if followed, can help pediatricians prevent kernicterus from occurring.
Newborns with kernicterus can develop a severe form of athetoid cerebral palsy, hearing loss and intellectual and other handicaps.
“The bulk of cerebral palsy is due to events that occur before birth and is not preventable, but if you can identify a baby who has a rising bilirubin level and treat that baby appropriately, you can prevent cerebral palsy caused by kernicterus,” Dr. Maisels said.
Because the condition is not monitored by the U.S. Centers for Disease Control and Prevention, solid data do not exist that would indicate an increased prevalence of kernicterus. However, reports in the literature and the number of medical malpractice lawsuits filed against pediatricians by parents whose babies suffer from kernicterus indicate that the condition still exists, and probably has increased in the last 15 years, according to Dr. Maisels.
In the 1940s and 1950s, kernicterus was a common complication of hyperbilirubinemia associated with Rh erythroblastosis fetalis and, occasionally, ABO hemolytic disease. However, kernicterus became less common with the introduction of exchange transfusion. In addition, the use of Rh immunoglobulin all but eliminated erythroblastosis fetalis, and phototherapy drastically reduced the need for exchange transfusion.
Shorter hospital stays may be a contributing factor to the current presence of kernicterus.
“Newborns used to stay in the hospital three to five days after birth so we could tell whether a baby was jaundiced before they went home,” Dr. Maisels said. “Bilirubin levels rise slowly and peak when an infant is 4 or 5 days old so that the level is always rising when an infant is discharged before 48 hours. This means that jaundice must now be managed as an outpatient problem.”
Studies found that infants with kernicterus (which is associated with extremely high serum bilirubin levels) often did not have hemolytic disease or other recognized causes of neonatal jaundice, according to Dr. Maisels. In fact, many appeared to be healthy, breastfeeding newborns. Frequently, however, the newborns were slightly premature and were not receiving adequate nutrition and hydration.
Newborns at increased risk of developing very high bilirubin levels often are jaundiced in the first 24 hours, or may be bruised and have a large cephalhematoma. Breastfed infants born at 34- to 38-weeks’ gestation and those receiving inadequate caloric intake are at particular risk.
Dr. Maisels stressed the importance of scheduling a follow-up examination one or two days after a newborn is discharged from the hospital. When that is not possible, he recommends measuring the newborn’s bilirubin level before discharge for a good estimate of the risk of a baby developing a high bilirubin level.
All bilirubin levels must be interpreted according to the infant’s age in hours, not days (Bhutani VK, et al. Pediatrics. 1999;103:6-14OpenUrl).
To increase the likelihood of preventing kernicterus Dr. Maisels said nurseries should develop a plan for identifying and managing jaundice in newborns. The total serum bilirubin level should be measured on every baby who is jaundiced in the first 24 hours with a repeat measurement four to 24 hours later.
Infants discharged from the hospital less than 48 hours after birth should be examined by their pediatrician within two days, and infants discharged less than 24 hours after birth may need to be seen within 24 hours after discharge.
Pediatricians should measure serum or transcutaneous bilirubin levels in infants of any age who appear significantly jaundiced. Infants with a bilirubin level exceeding 25 mg/dL should be hospitalized and placed under intensive phototherapy immediately.
For additional information, contact Carla Herrerias in the AAP Division of Health Policy Research at (800) 433-9016, ext. 4317, or e-mail, .